Rumination and Rumbling on Vascular Access...

​​VC: Peter Carr is a vascular access specialist and a research investigator at The University of Western Australia and Department of Emergency Medicine. He works at the Fiona Stanley Hospital, a major tertiary hospital in Perth Western Australia (WA). As a vascular access clinician and researcher, he tells me that he is "always learning, always researching and always sharing." ​In this vein (pun intended), I asked him to share with us his personal story of coming to the field and thinking about work in Australia, research and the future. He was kind enough to sit down with us to discuss for improvepicc.

Mr. Carr has disclosed that he has served on speakers bureaus CareFusion in 2013 and Becton Dickinson in 2014 providing lectures on vascular access. He received a grant from CareFusion to attend a scientific meeting and a part-funded Scholarship from Becton Dickinson to support research activities.

VC: Tell me a bit about yourself and your background/calling to vascular access.PC: I'm Irish which by default means I come from the most beautiful country in the world. However, I live in Perth, WA - the second most beautiful part of the world. If I want, I can cycle to work almost every day as the weather is super. I can even wear shorts in winter so what’s not to like!?

My professional interest in vascular access began in 2006 when I joined a European Working Time Directive initiative “IV Team”. A team of nurses and staff from the phlebotomy department provided peripheral intravenous cannulation to inpatients in Galway University Hospital; a teaching hospital in Ireland. While the service was disbanded due to the economic downturn, I had become motivated to research vascular access. My wife and I wanted a new adventure, a new challenge, to up skill clinically and academically so we departed the Emerald Isle taking a career leave from the Irish health service.

At that time the intention was to return and bring new knowledge/clinical methods back home. We have now been living “down under” for over 5 years and it looks like Australia is now our home and we appreciate the opportunity WA health have given us.

As a way of giving back to Australia, I am the current vice-president for the Australian Vascular Access Society and Scientific Chair for our 2nd Scientific Meeting. I am the Australian Global representative for World Congress on Vascular Access (WoCoVA) and lead the Western Australian Chapter of the AVATAR group. I won't be in these roles forever and the baton will be passed on in due course as change is a good thing (except for PIVCs!!).

VC: Tell me about your ongoing research work, interests and collaborators.PC: I'm currently researching a clinical prediction model for first-time insertion success. This is focussed on appropriate insertion of peripheral cannulae on the first attempt in an anatomical location that will have greater dwell (and therefore reduce subsequent attempts ) by a clinician who is confident to do so.

It is part of my PhD and is co-supervised by a leading ultrasound expert and Emergency physician James Rippey. If clinicians/health care service providers are unable to succeed with traditional attempts then the appropriate use of ultrasound will be a superior method. For my research it is important to be with a clinical and academic expert in this area as James is.

I found the world leading researcher in vascular access in Prof Claire Rickard of Griffith University. Claire had the only vascular access research group that I could find in the world. There is nothing like working and learning from the best. Myself James, Prof Marie Cooke, Dr Niall Higgins and Gabor Mihala are a great team. I contribute to the AVATAR group with some of the most passionate scientific minds who focus on making positive vascular access experiences for patients and eliminating complications using scientific methods. In a word, AVATAR is an inspiration. I am so lucky to be involved with it. I am busy with a Cochrane systematic review title and would love for a few RCT’s on specialist teams for successful device insertion and prevention of failure. So if any of your readers have a clinical trial registration, protocol and RCT on this subject, please feel free to send it my way.

VC: You have always believed that insertion skills matter most? Why so? PC: Well, insertion skill matters to the patient who receives the cannula, no? As clinicians we can be so focussed on trying not to miss and undertake repeated attempts without considering the feelings of the patient who is on the receiving end of the PIVC. Nothing beats genuine empathy. It is important for our colleagues to also understand that while insertion skill is critical, using the least appropriate device could result in a high failure rate on the first attempt or lead to a high post insertion failure. This requires us to be skilled in the assessment phase of the procedure and skilled in selecting the right devices suited to the patient.

I have seen and heard many comments such as “I can cannulate the small vein on your baby finger”. Well, find me a compos mentis adult who wants the PIVC in their pinky?

VC: So why has this issue not received more attention?PC: Because PIVC is so frequently performed by a range of professionals, no one owns the insertion skill and this results in fragmentation in expertise. Some get protected proctoring by the worst possible mentors and very few get the best. It’s the classic bystander effect in clinical care, someone else will teach it, someone else will sort out the infection, the difficult patient and so on.

Inserting invasive devices into patient's anatomy is a unique relationship between provider and patient and we need to accept that we can always do better. People who we are privileged to look after are not getting good enough outcomes; at best 70-86% (note, not a 100%) first-time insertion success; is this acceptable in 2016? What about the other 30%.

Even with the use of ultrasound, you won't get a first pass success publication over 85%. This is what the scientific literature is telling us. Last week I gave a local presentation about PIVC evidence for an ultrasound PIVC workshop. When I told the audience the effectiveness of USG PIVC (based on randomised trials) was no better than traditional attempts it was like I stole the goose that laid the golden egg. But it's not a personal opinion but what the evidence is telling us! The latest systematic review (one of 5) on USG PIVC by Shannon Parker and colleagues from Canada sheds some perspectives on this.

The fact is after insertion 25%-50% (note, not 0%) can fail because of avoidable complications. I love the “getting to zero literature for CLASBI OR CRBSI” and applaud the clinical champions involved in this work but wonder why can't we get to down to 1 attempt? Behind each percent, each number, is our core business; human life; people in need of help. Imagine you are in a hospital bed, tired from chemo on your 5th PIVC insertion in 6 days (bear in mind you’ve had 8 attempts between the last two) and your thinking about your life, your kids, dog and you are finally getting some clarity before you hear the occlusion alarm on your infusion pump indicating another failure. This means another attempt and possibly more unsuccessful ones at that.

This is happening 24/7 around the world and it is going unnoticed as it is unrecognised or deemed to be of less importance amongst the array of competing healthcare issues. My hope is for our research to contribute to improving the insertion skills of clinicians today and in the future.

VC: So how do you propose to measure the skill of the inserter?PC:We are working on a possible concept that we hope will attract funding (if you are a philanthropic reader, drop me a Tweet!). We (read as a generic term for Healthcare) poorly use data and poorly understand the relationship between data and vascular access regarding outcomes. One of those is the clinician's skill.

Let's say you had two medical/nursing inserters in the ED or Surgical ward, and on this occasion had to send 1 for mandatory PIVC training. Who would you send? (of course, some of your readers know this is a highly unlikely scenario… mandatory vascular access training that is) How would you pick the 1? The skill of the inserter is important, but they should want to be measured as a hospital mandate. Otherwise, we will continue with the keep trying until you get it approach; let's all have 2 attempts; call the anaesthetic to insert the PIVC or the local vein whisperer when all else fails.

Some clinicians reading this think they know how good they are, some might know how good they think they are, but what is their actual, factual data… if one of the aforementioned could say ”I put 50 PIVCs in this month; 44 traditional on the first needle puncture; 6 USG PIVCs on the first attempt. My outcomes are: 1 failed by accidental dislodgment, 29 remain insitu and 20 no longer needed and 0 infection/occlusion/thrombus. The category of patient was well spread between easy to difficult ones."

These data can help the manager allocate who they want to send for training. It's frustrating when people think they have data on the issue when they really don't. Because they have done the 2-4 hours mannequin venipuncture and cannulation training day and got someone to sign off on 20 insertions (if they got 20), they are ready for cannulation.

Do you think the patient should know what the success of the inserter is before he/she attempts one? Would you like your mother, father, brother sister, wife, husband, son, daughter to be the human simulator? We know (or at least I know) having observed 1,400 insertions in 2 large tertiary EDs with a variety of clinicians inserting that practice varies; training varies and success varies.

VC: Your research focuses a lot on the emergency department. Why did you choose this site as a venue for your study? PC: It is the front door of the hospital and the first exposure that most patients (notwithstanding pre-hospital attempts) have with invasive devices. In Australia, we have a national target to get patient assessed, admitted, transferred or discharged within 4 hours. PIVC insertion is ever present in ED admitted patients.

My clinical background is also in ED and my experience in vascular access have contributed to the concepts my research seeks to evaluate. ED is where vessel health and preservation should commence. In my opinion (but biased by my studies!) insertion practice is no different on the ward when compared to ED. Clinical practice should be no different, it should be as per policy.

Insertion skill is the final act in a long process of critical clinical decision making; this can happen in seconds or much longer. Not to get too deep into cognitive psychology, but this is where Type 1 and 2 of thinking is evident. It could happen very quickly with some and be influenced by their Gestalt or others may take time with a procedure.

We are about to finish analysis on a data set that looks at which provider we could resource to certain veins based on their confidence. My clinical academic colleague James Rippey is fascinated by the influence of clinician gestalt on first-time insertion success. We have a paper in press in Emergency Medicine Australia.

Simply put, we hope to test an application of rules in future to resource the least experienced with the best veins so they amass consistent insertion success, increase their confidence and continue to develop successful procedural consistency and experience with patients with the fewest visible veins.

VC: How can one get better at inserting peripheral IVs? Is there a course or training you would recommend?PC: It is a skill, an art and practice one can make permanent. You must know your product "intima"tely (pardon the pun) well. Your product target is a vein.

Jack LeDonne is a great friend and mentor, and he has a great saying “Feel is our fluoro” (this is the best advice he has told me). He’s right, though. The evidence to date is a visible palpable vessel is a strong predictor of insertion success. Don't set yourself up to fail; assessment is key. Once you can see and feel that vessel you approach it text book like (Aseptic-Sterile). You must be confident. Patient rapport and trust is important. Make them feel safe in your presence. Simple, really.

However, clinicians need to follow their outcomes. Imagine you’re the clinician who was at the pin of their collar so to speak, and got the PIVC in only for the device to fail by occlusion on the ward 6hrs later? Now the patient has the duty anaesthetist who has to make an extra attempt at an extra cost. These are modifiable and avoidable outcomes.

There are many courses one can take locally, online and many scientific meetings have pre-conference workshops. Seek out the local health care professionals whose paid role is to provide such training and mentorship. Ensure they actually perform clinical PIVC insertion themselves; I know may vascular access educators who insert vascular access devices in mannequins but not patients. That's a concern. Find the person who you think is the go-to person in your hospital, ask for mentorship/proctoring. Reflect on your performance.

VC: A lot of this comes back to having a dedicated group of providers to insert peripheral IVs? Is that your recommendation?PC: You ask an excellent question Vineet. Yes it most certainly does, and in my opinion not just for PIVCs but for all peripheral and central vascular access devices. I have been grounded into defending my answers where possible with an evidence base. We just don't have the evidence for dedicated groups though; by evidence I mean many RCTs- followed by Systematic appraisal and meta–analysis of the data proving this is the case.

By dedicated groups, we don't know if nursing vascular access team exclusively are better than a mixed healthcare professional model (nurses, doctors, RTs, PA’s) versus the general inserters. We have a Cochrane review coming out soon, and there is not one published RCT that randomises the patient (or indeed a registered protocol for one at the time of typing this) that suggests a dedicated group of providers is superior when compared to the current combination of medical, nursing, technician provision. There is an obvious evidence gap.

Of course, there is evidence that local single centre initiatives prove teams are associated with good outcomes, but no causal data. This comes back to clinical confidence and procedural competency not defaulting to a technology. If you were to run against Usain Bolt in the morning who would win the 100m sprint? If you were to compare a vascular access team member with an HCP who focuses on less frequent insertion, who may you think will have better outcomes? We can’t all get the gold medal, but I’m willing to take a bet that we can have improved and sustained insertion success and a huge reduction in failure and waste with a process that uses a dedicated group of providers. Then patients will have a gold standard.

VC: What types of policies need to be enacted in Australia to ensure consistent practice on a local/regional/national scale?PC: That is a tough one. As someone who has contributed to policy and guideline development, I respect the efforts that are made in writing them. However, based on current evidence I read daily, Australia needs an exclusive national vascular access device standard to include:

1. Better evidence-based assessment tools so we promote appropriate placement by appropriately trained professionals;2. Device registries in hospitals and better use of technology to capture data and report all outcomes, not just infection related. For example, alerts on previous line history, whether it was difficult or not. Some great work is being done with renal patients in this area in Australia;3. But the answer is in one word - consistent. Right now our first-time insertion success is “consistent” with 70-80% and post insertion failure is “consistent” 45%. Australia needs to continue to improve toward maintaining acceptable clinical outcomes for patients and aim for: “Consistent Practice” that reflects 100% first-time insertion success, 0% bloodstream infections, 0% complications through device failure.

In my opinion, the team approach to vascular access science is the biggest priority, and large metropolitan hospitals should have the professional entity that is “consistent” with practice approach. Otherwise, clinical decision-making will be underpinned by authority; let everyone have a go, rather than evidence.

Finally, with the development of our national society “AVAS”, we have ignited a flame for vascular access device practice and research to be promoted. That flame will continue to burn brightly next May in Perth with what we hope will be a cracking scientific meeting that will engage clinical practice with science, supported by the patient narrative. Toward better patient and hospital outcomes for Australia and afar. ​